Compelling commentary on children's health

A frightening little piece of research involving phthalates and babies appeared recently in the AAP journal Pediatrics.

A little background: Phthalates are manmade chemicals used in the manufacturing of a wide variety of cosmetics and personal care products. They’ve received a lot of attention due to their effects on male reproductive organs.

Little has been done to explore sources of phthalate exposure in babies, however.

Researchers reporting in the February Pediatrics measured phthalate derivatives in the urine of 163 infants and correlated these results with infant products applied to the skin. In 81% of the infants studied, phthalate metabolites were detected in the urine. Lotions, powders and shampoos were the culprits and the strongest association was found in the youngest babies. While the actual effect of this stuff on babies hasn’t been exactly worked out, it’s nonetheless scary stuff.

My prediction: More studies of this nature are likely to turn the infant cosmetic industry on its head. If there’s one thing that parents are obsessed with when it comes to their babies its safety.

At this time there is no standardized information on the phthalate content of specific infant products. And don’t expect it anytime soon. Instead look for small, independent phthalate-free manufacturers to set a new standard.

Ever wondered if my spoken voice is anything like my written voice? Well judge for yourself. Yesterday I was interviewed by Sree Sreenivasan, from the Columbia University School of Journalism. As the voice of new media in one of the most prestigious journalism programs in the country, it would seem that he’s shaking things up for the next generation of journalists. My interview was part of his “Blog CAT scan” where he dissects a blog and discusses potential points of improvement. His process offers valuable insight into what makes a blog successful. You can listen here on blogtalkradio.

The whole process had me wondering if I should be doing the same thing?

My family and I spent the weekend in Austin. During a walk in the city’s Arboretum district my son and I happened upon a time capsule that had been sealed in 1986. The plaque affixed to the small monument said that it was to be opened by the citizens of Austin in 2086. When I quipped that he should plan to show up at the age of 87 he suggested instead that we could both attend. He forgot or perhaps didn’t realize that this wouldn’t be possible.

I took the moment to remind him that I wasn’t going to be around forever. And at age nine, of course, such things begin to make sense. I could see the wheels turning as he put it all together. It was the first time he had ever had this realization. We talked about it for a bit and it was only a moment later that he was on to the next thing.

While a nine-year-old has the capacity to understand death, the real significance of a walk with your father on a near perfect spring day takes a little more maturity.

For stoolgazing parents nothing raises eyebrows like a bright green diaper. And it’s those shades of neon green that often stir a call to the pediatrician. So what’s the deal with green stool? Is it a problem or preoccupation?

Well take a seat and let's talk about the color of poop. Stool gets it’s color from bile released in the intestinal tract just beyond the stomach. Bile happens to be green. As it makes its way along the length of the intestinal tract, bile undergoes a transformation in color from its original green to a shade of yellow ultimately reaching a rich chestnut hue. I liken this transformation to the ripening of a banana.

Stool that reaches the end of its journey green or yellow typically means that the journey has gone a little quicker than expected. It’s typically nothing of concern although we can see this at times during a tummy bug. Green watery diarrhea in a child can be a problem in this case not because of the color of a baby’s poop but because of the potential for dehydration. So stool color has to be looked at in the context of a child’s other symptoms. If your child isn’t otherwise ill, a green diaper shouldn’t be cause for alarm.

Still the green stool spooks even the professional. I had a mother recently come very close to abandoning breastfeeding after being told by a lactation consultant that her baby’s green stools were the result of too much foremilk. The mom, desperate for her baby to produce the perfect diaper, tried to no avail to manipulate her baby’s feeding. While it was perhaps the only instance where I’ve seen micromanagement by an LC divide the mother-baby dyad, it’s just one example of the perils of stoolgazing.

So don’t let your preoccupation with stool characteristics become an obsession. And the next time someone frets over a green stool, send them this link.

Watch where you sit, there’s an encopresis epidemic underway. For the uniformed, encopresis is the medical term for accidental fecal soiling. In most children it occurs when stool backs up into the colon and leading to impaction and dilation of the rectum. We are dependent on subtle stretching of the rectal vault in order to tell us when something’s there. Kids with constipation lose rectal sensation and consequently lose their stool. It’s a humiliating condition often misunderstood as a psychiatric problem.

And it would seem to be more common than previously thought.

A new study from the University of Iowa published late last year estimated the prevalence (the percentage of the population with a particular condition) of encopresis in U.S. kids at 4.4%. Based on recent census bureau information for children between four and fourteen years of age it would appear that there are approximately 1.9 million children in the United States with encopresis.

These are big numbers. Sadly many parents are paralyzed by shame and guilt afraid to discuss the issue with even their pediatrician. I routinely treat such children and can typically get them clean within a couple of months. The solution involves three simple steps that most parents are quite capable of completing. But this is the subject of a much larger post.

As pediatricians we need to do a better job of raising encopresis public awareness. As parents you need to recognize that this isn’t your doing. And according to the latest research, you’re definitely not alone.

I used to be afraid of retail clinics because of their lack of follow-up, the absence of care by those with special training in treating children, and their advancement of a drive-through mentality to health care.

Now I have another reason to be concerned.

Buried deep in the bowels of yesterday’s Wall Street Journal (February 8, 2008, Media & Marketing, page B3) is a report on Wal-Mart and its new agreement with in store clinic operators. Beyond planning 2,000 retail clinics by 2014, Wal-Mart will mandate that clinics use an electronic medical records and practice management system from closely held eClinicalWorks.

Medical records would seem like an unlikely preoccupation for a retailer. But knowledge is power. As health care administrators would Wal-Mart have access to collective medical information and prescribing patterns just like the owners of a medical practice? If so, this would represent a new form of control for the world’s largest retailer.

Consistent with the view of the American Academy of Pediatrics, parents should mandate that their children receive care in a medical home where the most experienced clinicians diagnose, treat and follow children in a consistent way. For diapers and cereal, big box is good. But when it comes to your child’s medical needs or, more importantly, their privileged medical information, take the time and keep it under your pediatrician’s roof.

Political huckstering seems to have moved beyond automobile bumpers. This campaign season the trend is towards “party-training,” or the shameless promotion political candidates on t-shirts, onesies, bibs or any other attire worn by unassuming little citizens.

The MSM with what seems a shortage of fresh election news has sought the expert opinion of therapists to help us answer whether this is right or wrong. But this has little to do with psychologists. This comes down to making a decision how you choose to dress, or use, your children.

Call me as a ‘witholder’ but I’ll let my kids speak for themselves when they’re old enough to make such decisions.

Have you ever wondered if you’re a difficult parent in the eyes of your doctor? As a pediatrician, of course, I think a lot about parents. They carry the responsibility of doing what needs to be done for my patients. How I get along with them and how they get along with me naturally influences their child’s care. Like assessing any relationship, it’s helpful sometime to take stock of what you’re doing or not doing to make things better.

So what can you do to improve your parent-doctor relationship? More importantly, what are some simple things you can you do to increase the odds that your child will get the best care possible?

Be on time. Look at punctuality as the first sign that you’re serious about your child’s care. And while your pediatrician should value your time as much as his, don’t count on it even in a well-run office.

Remember you’re not the only one with a sick child. Boutique medical care is quickly becoming a thing of the 20th century, so reconsider the expectation of immediate callbacks and unlimited time in the exam room. Be prepared with your most important questions and make sure your key concerns are addressed before the close of the visit. Remember that the best doctors are always busy and that means that you’ve got to share his or her time and attention with lost of other families.

Treat the staff right. I’m always amazed at those parents who are nice to me and rude to my nurse. In a medical office everyone is involved in looking after the well-being of your child. And everyone talks. Do your best to cultivate a great relationship with everyone from the receptionist on up.

Don’t get caught in the web. Remember that is not your doctor’s responsibility to explain what you read on a web page. While your pediatrician should always be able to back up what he or she recommends, be careful about challenging their opinion with online information. Raw information will never take the place of experience and great judgment. Use the web to educate yourself but ultimately you have to have faith in the person you’ve chosen to be immediately responsible for your child.

If you don’t like something, politely state your case. Recognize your own concerns and if they’re not addressed, speak up. Doctors refer to a patient’s secret concerns as their ‘hidden agenda.’ It’s why they’re really there. Do your best to make that agenda clear and you’ll avoid the hard feelings that come with not having your mind read. If you’re not being heard or you’re afraid to open up, the relationship may not be working.

If it’s not working, find another doctor. Remember that what you share with your pediatrician is just as unique and complex as the relationship you share with a friend or close business colleague. And you need to recognize that what works for your neighbor may not work for you. Identify what you want in a doctor and look for it. You happiness will make you a better parent and ultimately a better advocate for your child.

Oh, and a couple of other things: Don’t demand antibiotics and always remember that your doctor may be just as frustrated as you are. Good luck and always remember that you bear the responsibility of representing your child.